Provider Demographics
NPI:1750585428
Name:ENGDAHL, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:ENGDAHL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1562 1ST AVE # 122
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-4004
Mailing Address - Country:US
Mailing Address - Phone:212-746-5454
Mailing Address - Fax:
Practice Address - Street 1:1562 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028
Practice Address - Country:US
Practice Address - Phone:212-746-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2018-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282N00000X
NY268129208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No282N00000XHospitalsGeneral Acute Care Hospital